1. Upper Limb
Orthopaedic Medicine

2. Scope
Neck
Shoulder
Elbow
Wrist
Hand

3. Neck Chronic pain syndromes. Mechanical neck pain. Red flags:
Weight loss, anorexia, fever, dysphagia, hoarseness.
Neurological signs in arm.

4. Neck X rays. Collars probably useless. Traction ditto.
Very poor correlation with symptoms.
80% of people over 50 years will have abnormalities.
CT / MRI: 30% of people under 40 have abnormalities.
Collars probably useless.
Traction ditto.
Encourage home exercises.
Simple analgesia.
Keep on with work and normal activities.

5. Shoulder Examination
Wasting of supraspinatus or infraspinatus suggests a rotator cuff problem.
Painful abduction arcs:
Starting at about 60° and easing or stopping after 120 ° suggests supraspinatus / cuff inflammation.
Starting at ° and continuing suggests OA of one or more joints.
Passively abduct to 90 ° and internally rotate, suggests impingement of supraspinatus.

6. Shoulder Examination
Can’t abduct due to weakness: passively abduct to 90 °, forward flex to about 30 ° and rotate internally (so the thumb points down). This isolates supraspinatus. Then ask ‘em to lower arm slowly – if it drops they have either a cuff tear or severe muscle atrophy.
Internal rotation: glenohumeral problems and frozen shoulder.

7. Shoulder Examination
External rotation: tendonitis of cuff muscles and frozen shoulder.
Passive, as opposed to active shoulder movements improve with tendonitis but not arthritis or frozen shoulder.

8. Shoulder Problems
Impingement syndromes(supraspinatus or rotator cuff tendonitis).
Common, =“rotator cuff syndrome”.
Pain often worse at night.
Pain during abduction (combing hair, reaching above head).
Chronically may lead to rotator cuff atrophy or tear.
Avoid precipitating factors.
NSAID’s.
Improving range of movement.
Steroids into subacromial bursa.
Surgical decompression (no use in rheumatoid).

9. Shoulder Problems Calcific tendonitis.
Hydroxyapatite deposits in supraspinatus tendon and subacromial bursa.
Presents acutely.
Check electrolytes and phosphate.
NSAID’s.
Steroid injection.

10. Shoulder Problems Biceps tendonitis.
Pain on carrying things with the elbow flexed.
If you inject the subacromial space some will get into the biceps sheath. Easier than getting the sheath !
NSAID’s.

11. Shoulder Problems Frozen shoulder. Women:Men, 3:1. Insidious onset.
Commoner after 50years.
Global restriction of movement, external rotation most reduced.
Physio – to gradually improve passive range of movement.
NSAID’s.
Glenohumeral steroid injection.
AC & sternoclavicular arthritis.

12. Shoulder Problems Glenohumeral arthritis. Rarer than other joints. OA.
Rheumatoid.
Crystal arthropathies.
Physio to encourage use.
NSAID’s.
Steroid less helpful.

13. Shoulder Problems Acromoclavicular arthritis.
Tenderness over the joints.
AC joint problems often secondary OA from earlier sporting injuries.
AC joint pain after 90 ° of abduction and continues.
Easy to feel crepitus.
Common in IV drug users.

14. Shoulder Problems Sternoclavicular arthritis. Tender over joint.
Most shoulder movements cause pain.
Common in IV drug users.

15. Elbow Medial epicondylitis. Commonest cause of elbow pain.
Pain on gripping.
Wrist extensors.
Forearm pain.
Chronic pain syndromes also get pain here.
Resisted wrist extension is painful in epicondylitis but not in chronic pain syndromes.

16. Elbow Lateral epicondylitis.
Wrist flexors.
Check ulnar nerve as entrapment may mimic lateral epicondylitis.
Pain on gripping.
Chronic pain syndromes also get pain here.
Resisted wrist flexion is painful in epicondylitis but not in chronic pain syndromes.
Bilateral epicondylitis – think of the neck.

17. Elbow Olecranon bursitis. Common in rheumatoid. Trauma.
Gout, pseudogout.
Infection.

18. Elbow “Pulled elbow”. OA. Often secondary to rheumatoid or trauma.
Restricted movement.
First to appear is restriction in extension then pronation / supination.
Pain closer to joint.

19. Wrist & Hand Objective synovitis is easy to feel.
If multiple joints think of systemic arthropathies.
Heberden’s and Bouchard’s nodes.

20. Wrist & Hand De Quervain’s tendonitis. Thumb OA. Finkslstein’s test.
Extensor pollucis longus and abductor pollucis brevis.
Avoidance of precipitants.
Wrist splint.
NSAID’s.
Possibly steroid injection into sheaths.
Thumb OA.
Common of the carpometacarpal joint.
Sore in anatomical snuff box.

21. Wrist & Hand Trigger finger. Carpal tunnel syndrome.
Modify gripping if possible.
NSAID’s.
Steroid injection.
Surgical decompression.
Carpal tunnel syndrome.
Should start with nocturnal pain – usually wakes them from sleep.
Should be proper dermatomal symptoms.